Provider Demographics
NPI:1164463691
Name:LACAYO, MARIANO S (MD)
Entity Type:Individual
Prefix:
First Name:MARIANO
Middle Name:S
Last Name:LACAYO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6101 BLUE LAGOON DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-3168
Mailing Address - Country:US
Mailing Address - Phone:305-500-2000
Mailing Address - Fax:
Practice Address - Street 1:975 W 49TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-3412
Practice Address - Country:US
Practice Address - Phone:786-281-5358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89783207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL31138OtherBCBS
FLME89783OtherMEDICAL LICENSE
FL108910900Medicaid
FLI07594Medicare UPIN